=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780854901
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GASTROENTEROLOGY (DIGESTIVE) AND NUTRITION CENTER, PSC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/04/2008
-----------------------------------------------------
Last Update Date | 01/12/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | STA. CRUZ ST. #73 EDIFICIO MEDICO SANTA CRUZ SUITE 403
-----------------------------------------------------
City | BAYAMON
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00961
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-786-3110
-----------------------------------------------------
Fax | 787-786-3120
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | STA. CRUZ ST. #73 EDIFICIO MEDICO SANTA CRUZ SUITE 403
-----------------------------------------------------
City | BAYAMON
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00961
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-786-3110
-----------------------------------------------------
Fax | 787-786-3120
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MARCIA R CRUZ-CORREA
-----------------------------------------------------
Credential | MD, PHD
-----------------------------------------------------
Telephone | 787-786-3110
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 12414
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------